Early results of displaced supracondylar fractures of humerus in children treated by closed reduction and percutaneous pinning

Background:

Displaced supracondylar fractures are notorious for difficulty in reduction, maintenance of reduction and frequent involvement of neurovascular structures. No general agreement on the treatment is evident with controversy prevailing regarding the ideal timing of surgery, method of maintenance of reduction and configuration of the pin fixation. A crossed pin configuration, though believed by some to be mechanically more stable than the lateral pins alone, has the risk of ulnar nerve injury due to the medial pin. Lateral pins alone impart less rotational stability to the fracture although it has been attributed mainly to technical errors of pin placement. The aim of this study was to assess the efficacy of treatment of this fracture using one lateral and one trans-olecranon K-wires or lateral entry K-wires alone.

Materials and Methods:

Ninety cases of displaced supracondylar humerus fractures were included in the study. The mean age of the patients was 6.7 years (range 3–12 years). The male/female ratio was 5:1 and left side was involved in 70% whereas 30% had right sided injuries. The most common mode of trauma was fall from height with elbow in extension. All the 90 consecutively admitted patients had extension type injury with 73.3% fractures being Gartland type III and 26.7% were type II. Posteromedial displacement was noted in 70% whereas 30% fractures were posterolaterally displaced. In 60 cases, lateral entry wires alone were used whereas, in 30 cases, one lateral and another transolecranon transarticular K-wire was used. K-wires were removed at 3 weeks postoperatively and followup was done at 6 weeks and 12 weeks when they were evaluated according to the criteria described by Flynn. Chi-square test was used as a statistical test of significance to compare results among different variables.

Results:

Results were graded according to Flynn''s criteria. Excellent results were achieved in 12 (13.3%), good in 54 (60%), fair in 15 (16.7%) while in nine patients (10%) poor results were obtained.

Conclusions:

Both lateral entry K-wires and lateral-trans-olecranon wire techniques provide stable fixation when observing the guidelines for wire placement and consistently satisfactory results can be obtained, both cosmetically and functionally with both the techniques.     

闭合复位经皮克氏针内固定治疗儿童不稳定肱骨髁上骨折

目的探讨C臂X线机透视下闭合复位经皮克氏针内固定治疗不稳定儿童肱骨髁上骨折的疗效。方法C臂X线机透视下闭合复位经皮克氏针内固定术治疗儿童不稳定肱骨髁上骨折35例。结果35例均获随访,时间7～13个月。术后无缺血性挛缩,3例出现针孔渗出较多,经加强换药后痊愈。无一例出现肘内翻、尺神经损伤。按Flynn标准评价：优20例,良15例,无一般及差病例。结论C臂X线机透视下闭合复位经皮克氏针内固定治疗儿童不稳定肱骨髁上骨折手术创伤小,固定可靠,可以获得良好的肘关节功能和外形。     

Comparison of clinic-radiological outcome of cross pinning versus lateral pinning for displaced supracondylar fracture of humerus in children: A randomized controlled trial

IntroductionSupracondylar fracture of humerus (SFH) is frequently encountered in the immature skeleton, [1] predominantly in the non-dominant extremity.AimThis study compared the clinic-radiological outcome between cross pinning with lateral pinning for fixation of displaced supracondylar fracture of humerus in children.Materials and methodsAll eligible patients were randomized into two groups, group I for lateral pinning and group II for cross pinning. Before passing medial pin in group II a stab incision was given to visualise the medial epicondyle. Patients were followed up on 3 weeks, 6 weeks and 3 months. Final outcome was measured in terms of clinic-radiological union, Baumann angle, loss of reduction, stability of fracture fixation, incidence of iatrogenic nerve injury and Flynn's score. Results: There were 37 patients in group I and 40 in group II. Both groups were comparable in terms of demographic details. At the final outcome there were no difference in between the groups in terms of all radiological and clinical outcome. Two patients of group I developed delay ulnar neuritis, which resolve completely in subsequent follow-up.ConclusionBoth techniques provide stable fixation, union and good functional outcome without iatrogenic ulnar nerve injury provided that small incision sufficient enough to identify the medial epicondyle is given with passing of medial pin.     

Lateral versus crossed wire fixation for displaced extension supracondylar humeral fractures in children

Reduction and percutaneous pin fixation is widely accepted treatment for displaced humeral supracondylar fractures in children, but the best pin configuration is still debatable. This study examined the outcome for crossed and lateral pins placement in type IIB and III supracondylar humeral fractures. Clinical notes and radiographs of 131 children with an average age of 6 years were retrospectively reviewed. Lateral pins fixation was used in 66 children and crossed wires in 65. The groups were similar with regard to gender, age, follow-up, severity of displacement and number of closed/open reductions. There was no statistical difference between the two groups either clinically or radiologically in the quality of outcome. However, postoperative ulnar nerve injuries occurred in 6% of patients treated with crossed wire fixation, whilst none of the group with pins inserted laterally suffered this complication. We recommend fixation of displaced humeral supracondylar fractures with two or three lateral pins inserted parallel or in a divergent fashion. This method of fixation gives similar results to crossed wires but prevents iatrogenic ulnar nerve injuries.     

Results of treatment of displaced supracondylar humeral fractures in children by percutaneous lateral cross-wiring technique

Seventy children with displaced type II and III supracondylar fractures of the humerus were managed with percutaneous lateral cross-wiring technique from January 2006 to January 2007. There were 54 boys and 16 girls with a mean age of 6.1 ± 3.07 years. All patients were operated within 24 h after trauma using the Dorgans percutaneous lateral cross-wiring technique. Patients were followed up for a mean period of 6.1 ± 2.6 months and assessed both radiologically for union; and functionally and cosmetically according to Flynn’s criteria. All patients achieved solid union. Functionally, all patients achieved satisfactory results, while cosmetically, 91.4% of patients had satisfactory results and 8.6% had unsatisfactory results. The most frequently occurring complications were minor pin tract infection in six patients, deep infection in two patients, and 32 patients suffered excessive granulation tissue formation mostly around the proximal pin. There was no iatrogenic neurological injury either for the ulnar or for the radial nerves. The obtained results and minor complications reported signify this technique as a viable treatment method for displaced type II and III supracondylar fractures in children.     

Displaced supracondylar humeral fractures in children: open reduction vs. closed reduction and pinning

Introduction In the literature the best results for pediatric supracondylar humerus fractures have been achieved by closed reduction and wire fixation. However, in these reports the patient group of open reduction and pinning contained the patients who had had previous ineffective closed reduction trials. This retrospective study compared open and closed reduction with pinning, in which the first group of patients was all consecutively treated with open reduction.Materials and methods The study included 99 children with displaced extension-type supracondylar fractures of humerus who had complete follow-up. Open reduction patients had not had a previous attempted closed reduction. Open reduction and pinning were performed through a posteromedial incision in the first 44 patients and closed reduction and pinning in the subsequent 55 patients. Mean duration surgery was 15 h with open reduction and 17 h with closed reduction. Mean follow up was 35 months with the open reduction and 21 months with closed reduction. Humeral-ulnar angle was compared to the contralateral elbow, clinical flexion deficiency and extension lag, and complications were evaluated.Results At the latest follow-up the open group had an average of 5.1° valgus change and the closed group 3.6° valgus change in humeral-ulnar angle compared to their uninvolved elbow. Average flexion deficiency was 8.61° in the open and 5.25° in the closed group. Average extension lag was 6.23° in the open and 0.6° in the closed group. Functional results were satisfactory in 71% of patients in the open and 93% of those in the closed reduction group. Cosmetic results were satisfactory in 95% of both groups.Conclusions Closed reduction and pinning is superior to open reduction and pinning for the treatment of pediatric supracondylar humerus fractures. In the case of technical insufficiencies open reduction and pinning through a posteromedial incision is an alternative treatment for decreasing the surgical time and complications. Complications was not caused in either group by the delayed surgical timing compared to reports in the literature.     

Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: a systematic review

Purpose  

There is no clear evidence in the actual literature regarding which of the surgical approaches could bring about the best functional, cosmetic, and radiological outcomes, as well as fewer complications, when an open reduction and pinning of a severely displaced supracondylar humerus fracture is performed. We, therefore, performed a systematic review of the English literature to investigate the existing evidence regarding this issue.     

Timing of surgical treatment for type III supracondylar humerus fractures in pediatric patients

Background  Type III supracondylar humeral fracture is a common cause of emergency hospitalization among children requiring surgical treatment. The configuration of the internal fixation material, surgical technique, and optimal timing of surgery (TS) have always been popular topics of debate. The TS in uncomplicated cases is usually determined by surgeons. Methods  In this study, we prospectively followed children with type III supracondylar fractures. We aimed to clarify the effects of injury side, gender, and post-injury delay on switching to open surgery and the ease of the reduction. Results  Based on our results, the probability of switching to open surgery increased by a factor of 4 every 5 h beginning 15 h after injury. Open surgery was necessary after 32 h. Conclusion  Reduction became technically more difficult as TS increased.     

Closed reduction and percutaneous pinning of displaced supracondylar fractures of humerus in children with delayed presentation

Objective: Supracondylar fractures of the humerus account for 60% of all the fractures around the pediatric elbow and even in developed countries 18% of patients undergo surgery 48 hours or longer following presentation in the hospital. Management guidelines are not clear yet for these patients who present late. The aim of this prospective study was to evaluate the clinical, radiological and functional outcome following closed reduction and percutaneous pinning of widely displaced supracondylar fractures of the humerus presenting 12 hours or more after injury.Methods: We reviewed the functional and radiological results of closed reduction and percutaneous pinning using crossed K-wires in 40 patients with displaced extension type supracondylar fracture of the humerus (Gartland type Ⅲ) with a delay of more than 12 hours in presentation. The average age of patients was 4.5 years and the mean delay in presentation was 17.55 hours.Results: Closed reduction and percutaneous pinning was successful in 90% of patients. The mean follow up period was 15 months. The Baumann's angle was restored within 4 degrees of the unaffected side in all patients. Use of a small medial incision in patients with severe swelling helped us avoid ulnar nerve injury. Using Flynn's criteria,38 patients (95%) had an excellent result. Two patients had mild myositis and both had a poor result. None of the patients developed cubitus varus.Conclusion: Closed reduction and crossed pinning of displaced supracondylar fractures of humerus in children is a safe and effective method even with delayed presentation.     

Comparison of closed reduction and percutaneous pinning versus open reduction and percutaneous pinning in displaced supracondylar fractures of the humerus in children.

A retrospective review of 29 children with displaced supracondylar humerus fractures was performed. Fifteen patients treated with closed reduction and percutaneous pinning and 14 patients treated with open reduction and percutaneous pinning were evaluated at a minimum of 18 months (range 18-80 months). Results were graded according to the criteria of Flynn et al. (Flynn JC, Matthews JG, Benoit RL: Blind pinning of displaced supracondylar fractures of the humerus in children. J Bone Joint Surg [Am] 56:263-272, 1974) using both cosmetic and functional evaluations. Excellent or good results were obtained in 14 of the 15 fractures treated with closed reduction and percutaneous pinning and in 12 of the 14 fractures treated with open reduction and percutaneous pinning. The three fair cosmetic results were associated with inadequate reduction and residual medial angulation. Ten to 15 degrees of motion loss occurred in three older patients. One patient in each group had a minor pintract infection. There were no cases of iatrogenic nerve injury or myositis ossificans. The treatment goal in displaced supracondylar humerus fractures in children is anatomic reduction. If an anatomic reduction cannot be achieved with closed reduction, open reduction is indicated. This can be done without an increased risk of complications.     

Controversial topics in the management of displaced supracondylar humerus fractures in children

The aim of our study was to review the literature looking for the up to date information regarding these controversial topics. An electronic literature search was performed using the Medline/PubMed database. A closed reduction attempt should always be done first. It is more important to engage both columns as well as divergence of the pins no matter whatever configuration is applied. Time to surgery seems to be not an important factor to increase the risk of complications as well as open reduction rate. Usually neurological injuries present a spontaneous recovery. If there is absent pulse, we should follow the algorithm associated with the perfusion of the hand.     

Morote pinning for displaced midshaft forearm fractures in children

Surgical Principles Internal fixation of displaced midshaft or proximal forearm fractures in children or adolescents without violating the epiphyseal growth plate (physis) can be achieved with intramedullary implants. From a distal approach, the displaced fragments of the radius are aligned with the blunt end of a pre-bent Kirschner wire and reduced. In a second step, the ulnar fracture is reduced and fixated intramedullarily through a proximal approach. An external immobilization is advised for two to four weeks. Intramedullary pins or nails for the treatment of forearm fractures have been in use for years. Kirschner wires [1, 2, 3, 4, 6, 12], Rush pins [13] and Hackethal bundle nails [5] were tried. This new technique was first published in the Spanish literature by Perez-Sicilia et al. [11] in 1977. J. L. Morote Jurado introduced us to his method in 1983. A similar principle of treating forearm fractures in children was published by Buch et al. [3]. Elastic intramedullary nails have been used by the school of Nancy [7, 9, 10, 14]. Revised Version from: Operat. Orthop. Traumatol. 2 (1990), 245–255 (German Edition).     

Evaluation of the short-term results of closed reduction and percutaneous K-wires fixation of displaced intra-articular calcaneal fractures (DIACF)

PurposeOptimum management of displaced intra-articular calcaneal fractures (DIACF) still controversial. Open surgery carries the risk of wound complications, while non-operative management has a high incidence of arthrosis. To avoid these complications, minimally invasive and percutaneous fixation was introduced. The purpose of this study was to prospectively evaluate the short term clinical and radiological outcomes after closed reduction and percutaneous fixation of DIACF using K-wires.Patients and methodsOutcomes of twenty patients were evaluated at the final follow up. A functional assessment using the AOFAS scoring system. Radiological parameters recorded included three angles (Böhler’s, Gissane and posterior facet inclination angles) and three distances (calcaneal length, height and width). Any complications were reported at any follow-up.ResultsThe mean patient’s age was 33 ± 15.2 years, 8 (40%) patients with type II fractures, 10 (50%) patients with type III fractures, and 2 (10%) with type IV fracture according to Sanders classification. After a mean follow-up of 9 months, the mean AOFAS score was 84, excellent in 9 patients (45%), good in 9 (45%), and fair in 2 (10%). At the final follow-up the Böhler’s angle, Gissane angle and PFIA was 25.1° ± (5.2), 119.9° ± (9.4) and 51.7° ± (5.9) respectively and the calcaneal height, length and width was 41.8 mm ± (2.1), 75.1 mm ± (3.01) and 40.9 mm ± (2.6) respectively. We had no cases of deep infection, 20% had significant subtalar arthritis.ConclusionThe closed reduction and percutaneous fixation technique for DIACF management offered acceptable clinical and radiographic outcomes, with fewer complications when compared to other management options.     

Ascending cluster pinning of the humerus inserted through the deltoid tuberosity

Summary Goal of Surgery Stable internal fixation of extraarticular proximal humeral fractures. Indications Extraarticular fractures angulated more than 30° which can be reduced closely or through a small incision. Epiphysiolysis. Fracture-dislocation of the humeral head. Contraindications Pathological fractures. Four part fractures. Segmental fractures of the humerus. Positioning and Anaesthesia Supine; the affected shoulder overhanging the edge of the table and supported by a radiolucent board. General or regional anaesthesia. Surgical Technique Closed pinning of two part and certain three part fractures of the proximal humerus being displaced, unstable, and mainly at the metaphyseal level. Introduction of Kirschner wires through a diaphyseal window and advancement into the proximal fragments after reduction which is controlled by image intensification. Postoperative Management Temporary immobilization in a sling. Passive and active assisted movements after a few days. Active movements after 2 weeks. Removal of wires after 3 months. Possible Complications Fracture of the humerus at the site of the cortical window. Injury to the radial nerve. Results 32 patients, mean age 49 years, 30 two part fractures and 2 three part fractures. Number of Kirschner wires used: 3 to 6, mean 4. Two out of 3 patients complained of pain at the site of wire insertion. All fractures consolidated. No avascular necrosis nor infection. Complications: Partial loss of internal fixation in 3 patients. One fracture of the humeral shaft. Sympathetic reflex dystrophy in 3 patients. Half of the patients had a normal range of motion. Time of follow-up: 6 to 24 (mean 10) months. Division of Orthopaedics and Traumatology, Purpan Hospital, Toulouse, France.     

移位型儿童肱骨髁上骨折的治疗选择

<正>儿童肱骨髁上骨折是儿童肘部的最常见损伤类型,发病高峰出现在4～8岁[1],易出现肘内翻后遗症。本骨折属于肘部的严重损伤,尤其对于移位显著病例,常并发神经损伤,甚至发生血管功能障碍,导致出现更为严重的间室综合征,处理不当可造成Volkmann挛缩,形成终身病废。因此,儿童肱骨髁上骨折应尽早予以麻醉下闭合复位、经皮穿针并辅以长臂石膏后托固定肘     

Complications and timing of follow-up after closed reduction and percutaneous pinning of supracondylar humerus fractures: follow-up after percutaneous pinning of supracondylar humerus fractures

The purpose of this study was to evaluate the need for clinical evaluation with radiographs within 10 days of closed reduction and percutaneous pinning for the treatment of displaced supracondylar humerus fractures. Between May 1 and December 31, 2001, the authors evaluated the complications with closed reduction and percutaneous pinning of 104 displaced supracondylar humerus fractures. Fifty-two of the patients had the initial follow-up examination with radiographs 10 days or less after pinning; the other 52 patients had the initial follow-up examination with radiographs either after 10 days or on the day of pin removal. The overall complication rate for the series was 7.7% (8/104). All eight complications were in type III fractures. The early follow-up group had six complications; the late follow-up group had two complications. Baumann's angle, lateral humerocapitellar angle, and lateral rotational percentage were not significantly different between the two groups. The only variable tested that was associated with a complication was pin configuration. No association between late follow-up and complications was identified. The authors conclude that clinical and radiographic evaluation of routine displaced supracondylar humerus fractures requiring closed reduction and percutaneous pinning may be safely delayed until pin removal.